Brief discussion of Crohn disease from pathological point of view

1. What's the relationship?

2. Case
A 25 YRS old male presented with central
abdominal pain associated with low grade
fever
And intermittent attacks of diarrhrea that come
and go in a weekly pattern . The pt. was anorexic
and metioned a gradual weight loss over the
past few months . also the pt. is smoker since
he was 17 .

3. Case discussed
A 25 YRS old male presented with central
abdominal pain associated with low grade
fever
And intermittent attacks of diarrhrea that come
and go in a weekly pattern . The pt. was anorexic
and metioned a gradual weight loss over the
past few months . also the pt. is smoker since
he was 17 .

4. !Lets go DDX
 Bacterial enteritis
 Viral enteritis
 Ulcerative colitis
 Tumor
 Crohn's disease

5. So what's the approach ??
Full history : the pain questions , diarrhea , stool
characteristics , family Hx of similar condition, social
habits including smoking .
 Clinical examination
 Lab investigations : complete blood picture
showed ( megaloblastic anemia?)
elevated ESR and CRP , folic acid and Cu defeciency
GSE for presence of bacteria . Stool occult blood test

6. Approach
 Colonoscopy , CT scan , X-RAY with barium enema .
(no mass , but narrowing of bowel lumen)

7. inflammation
Edema
and
fibrosis
Narrowed
lumen
Of the wall
of intestine

8. AT
ENDOSCOPY
(if possible)

9. What to see ??
• Mucosa : small ulcers coalesce to
form long serpentine linear ulcers .
The mucosa between the ulcers is
inflamed and edematous , having a
cobble-stone appearance .

10. Ulcers and stones

11. They love this one :
the sharp demarcation of diseased bowel
segments from the adjacent non involved
essentially normal bowel .

12. Ulcers or fissures ??
• The superficial ulcer may penetrate deeply to
form deep fissures , these may extend further
causing fistulae between the affected
intestinal segment and :
• Bowel loops
• Vagina
• Bladder
• Skin of abdomen

13. Biopsy taken for
bacteriologic
and
pathologic
studies

14. The Bx results

15. GO microscopically
• Acute mucosal inflammation ; neutrophils in the
epithelium and in the crypts (crypt abscesses )

16. GO microscopically
• Chronic mucosal damage : this is
villous blunting in SI , and crypt
irregularity in the LI .
• Ulcerations
• Trans-mural chronic inflammation :
lymphocytes and plasma cells fill all
the layers

17. Non caseating granuloma

18. GO microscopically
• Other changes ; duplication and thickening of
musc. mucosae. And also fibrosis of
submucosa , musc. Propria and serosa .
• Dysplastic changes in the mucosal epithelial
cells : this is imp. In long standing disease ,
may be focal or widesprad , increase with time
this increases the risk of CA . Esp. that of colon

20. C / F
• Colicky abdominal pain
• Intermittent attacks of diarrhea
• Fever lasting weeks or months
• Anorexia , Wt loss
• Anemia in colon involvement

21. Complications of Crohn's
• Fibrosing strictures : causing intestinal
obstruction ( symptoms ?)
• Fistulae to ; normal bowel , vagina , bladder
• Extensive involvement of small intestine :
causing protein losing enteropathy ,
pernicious anemia (?) , steatorrhea (?) and
generalized malabsorption .

22. EXTRA-INTESTINAL MANIFESTATIONS
• Arthritis
• Finger clubbing
• Erythema nodosum
• Primary sclerosing cholangitis
• renal disorders (how ?)
• systemic amyloidosis
• increased incidence of CA of GIT
Ureter
trapped in
inflamed
bowel
narrowing
Urine
back to
kidneys
Hydronephrosis

23. Cigarette
smoking is a
risk factor
for Crohns DR, Bernard Crohn
Clubbing is an extra
intestinal manifestation
for Crohns
Cobble stone
pavements